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Extra Help With Medicare Prescription Drug Plan Costs

1. Find Out If You Qualify
2. Complete Application
3. Review
4. Submit
5. Print Receipt

The Application For Extra Help With Medicare Prescription Drug Plan Costs was received by
Social Security on June 14, 2016, 8:21:53 PM.

Successful Submission - Print Or Save Your Receipt

We recommend that you print or save this page for your records. We have included the exact details of
your submitted application. For instructions on how to print, save, or view the saved file, please refer
to the Print/Save/View Guide.

Select this link to print this page or save it to your computer.

About You and Your Spouse

You

Name:harold f back
Social Security Number:* * * - * * - 8194
Date of Birth:March 2, 1936

Spouse

Name:dianna b back
Social Security Number:* * * - * * - 0057
Date of Birth:July 5, 1940

About You and Your Spouse

You

Have you worked in 2015 or 2016? No

Spouse

Has your spouse worked in 2015 or 2016?No

Mailing Address:595 e pierce st, lake alfred, Florida, 33850

We have not changed our address within the last three months

Telephone Number:(863) 875-2205

If your spouse has Medicare (or expects to have it in the next three months), does he or she also wish
to apply? Yes
Do you have combined savings, investments, and real estate worth more than $27,250?No or Not Sure
Medicare Savings Programs: Not Interested
If you would prefer that we contact someone else if we have additional questions, please provide the
person's name and daytime phone number: harold f back, (407) 247-1484

About Your And Your Spouse's Living Situation

For this question, a relative is someone related to you by blood, adoption, or marriage (but not
including your spouse). How many relatives live with you and depend on you or your spouse for at
least one-half of their financial support?0

Resources

Do you or your spouse have bank accounts (checking, savings and certificates of deposit)? Yes, we
have $1,760.00
Do you or your spouse have stocks, bonds, savings bonds, mutual funds, Individual Retirement
Accounts (IRAs) or other similar investments? Yes, we have $274.00
Do you or your spouse have any other cash at home or anywhere else? No
Will some money from any of these sources be used to pay for your funeral or burial expenses? No
Will some money from any of these sources be used to pay for your spouse's funeral or burial
expenses?No
Other than your home and the property on which it is located, do you or your spouse own any real
estate?No

Income Other Than Wages And Earnings

Do you receive income from Social Security benefits? Yes, $1,060.00 per month
Does your spouse receive income from Social Security benefits? Yes, $700.00 per month
Do you receive income from Railroad Retirement benefits? No
Does your spouse receive income from Railroad Retirement benefits? No
Do you receive income from Veterans benefits? No
Does your spouse receive income from Veterans benefits? No
Do you receive income from other pensions and annuities? No
Does your spouse receive income from other pensions or annuities? No
Do you receive income from other income not listed above, including alimony, net rental income,
workers' compensation, unemployment, private or State disability payments, etc.? No
Does your spouse receive income from other income not listed, including alimony, net rental income,
workers' compensation, unemployment, private or State disability payments, etc.? No
Has any of the income from these sources decreased in the last two years?No

If you need help completing this application, call Social Security toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm

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